The Obama health-care plan passed 18 months ago, and its cynicism still manages to astonish. Witness the spectacle surrounding one of its flagship new entitlements, which is eliciting some remarkable concessions from its drafters.

The Health and Human Services Department recently shut down a government insurance program for long-term care, known by the acronym Class. HHS also released a statement claiming that reports that HHS is shutting down Class are "not accurate." All HHS did was suspend Class policy planning, told Senate Democrats to zero out Class funding for 2012, reassigned Class's career staffers to other projects and pink-slipped the program's chief actuary. Other than that, it's full-speed ahead.

HHS is denying what everyone knows to be true because everyone also knows that the Class entitlement was not merely created to crowd out private insurance for home health aides and the like. Class was added to the bill because it was among the budget gimmicks that Democrats needed to create the illusion that trillions of dollars of new spending would somehow reduce the deficit.

Benefits in the Class program, which was supposed to start up next year, are rigged by an unusual five-year vesting period. So the people who sign up begin paying premiums immediately—money that Democrats planned to spend immediately on other things, as if the back-loaded payments to Class beneficiaries would never come due. The $86 billion or so that would have built up between 2012 and 2021 with the five-year lead is supposed to help finance the rest of ObamaCare. The Class program would go broke sometime in the next decade, but that would be somebody else's problem.

Corbis .Opponents warned about this during the reform debate, and people on HHS's lower rungs were telling their political superiors the same thing as early as mid-2009, according to emails that a joint House-Senate Republican investigation uncovered.

In one 2009 note, chief Medicare actuary Richard Foster—a martyr to fiscal honesty in the health-care debate—wrote that "Thirty-six years of actuarial experience lead me to believe that this program would collapse in short order and require significant Federal subsidies to continue." He suggested that Class would end in an "insurance death spiral" because the coverage would only be attractive to sicker people who will need costly services. It could only be solvent if 230 million Americans enrolled, which is more than the current U.S. workforce.

An HHS Office of Health Reform official, Meena Seshamani, rejected Mr. Foster's critique because "per CBO it is actuarially sound." But of course CBO only scores what is presented to it, no matter how unrealistic. Despite this false reassurance, later even one HHS political appointee took up Mr. Foster's alarms, writing that Class "seems like a recipe for disaster to me."

In February of this year, Health and Human Services Secretary Kathleen Sebelius finally admitted the obvious, testifying at a Congressional hearing that, gee whiz, Class is "totally unsustainable" as written. By then Class had become a political target of vulnerable Senate Democrats looking to shore up their fiscal bona fides, despite voting for it when they voted for ObamaCare.

Bowing to this political need, Mrs. Sebelius has repeatedly promised to use her administrative discretion to massage Class's finances until it is solvent. But given that the office doing that work has now been disbanded, this evidently proved impossible, as the critics claimed all along.

***All of this would seem to make repealing Class an easy vote for Congress, but, this being Washington, it isn't. Since the CBO says Class's front-loaded collections cut the deficit to the tune of that $86 billion, HHS has to pretend that the program is still alive to preserve these phantom savings.

Some Republicans are also nervous about repealing Class because, under CBO's perverse scoring, they'll be adding $86 billion to the deficit. Others would prefer not to repeal any of ObamaCare until they repeal all of it, on grounds that some of it might survive if the worst parts go first.

So an unaffordable entitlement that will be a perpetual drain on taxpayers may continue to exist because of a make-believe budget gimmick that everyone now admits is bogus. Congress can't reduce real future liabilities because it would mean reducing fake current savings.

This is literally insane. It's rare to get a political opening to dismantle any entitlement, much less one as large as Class. House Republicans ought to vote to repeal it as soon as possible as an act of fiscal hygiene, forcing Senate Democrats to vote on it and President Obama to confront (even if he won't acknowledge) the fraud he signed into law.

By LOUISE RADNOFSKY Every Republican presidential candidate has promised to repeal the Obama administration's health-care overhaul. But despite full-throated criticism, it's going to be hard for any of them to fulfill that pledge if elected.

Despite their full-throated pledges to repeal the health overhaul law, no Republican presidential candidate is likely to fulfill that pledge entirely if elected in 2012. Louise Radnofsky has details on The News Hub..Standing in the way of that seemingly simple campaign promise—an article of faith among GOP voters—is a welter of practical and political obstacles. They include immovable limits on what elements the Senate can tackle, in the likely event Republicans don't have a 60-seat majority after the 2012 election, and the party's need to come up with spending cuts to replace savings promised by "ObamaCare," as it's dubbed by critics.

These and other hurdles have sparked a lively debate among the candidates over whose approach is best, with former Massachusetts Gov. Mitt Romney battling rivals who say his two-step plan is unrealistic. For now, GOP lawmakers and conservative strategists are pushing separate, piecemeal approaches.

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Close.The conundrum is in part a direct consequence of the law's complexity, something Democrats now consider an asset. In the House, some Republicans have been studying ways to choke off funds for the law while working toward repeal, while in the Senate Republicans are pushing bills to knock out specific pieces of the law.

The complications are evident in Mr. Romney's two-step plan.

Mr. Romney has proposed signing an executive order on "day one" offering waivers to any governor who wants his or her state to opt out of the law. His rivals note that by law, such waivers can't take effect before 2017. The move would also leave untouched the focus of conservative opposition: the requirement that individuals carry insurance or pay a fee.

Mr. Romney said he would follow this on "day two" with legislation to repeal the law, using a Senate tactic called budget reconciliation. That would require only 51 votes to succeed, a total the GOP might reach after next year's election.

But under the rules, such a bill would tackle only parts of the legislation that relate directly to the budget. Anything else would require 60 votes to overcome a Democratic filibuster, and few see Republicans notching that number.

MoreWashWire: Poll: Most Don't Like Health-Care Law .Presidential contenders Rick Perry and Jon Huntsman have attacked Mr. Romney's approach, particularly the first step of his plan.

"Ultimately there are no administrative silver bullets that can roll back the core provisions," said Tim Miller, a spokesman for Mr. Huntsman. Mark Miner, a spokesman for Mr. Perry, said the candidate would do "as much as is possible through executive order, but will focus on leading Congress to pass a full repeal."

In addition, some provisions of the law are linked with others and would cause problems for health insurers if dismantled. Moreover, while polls show a plurality of the public backs repeal, people also favor certain pieces of the bill.

In a March 2011 survey by the non-partisan Kaiser Family Foundation, 74% said they thought lawmakers should keep provisions that prohibited insurance companies from denying coverage because of a person's medical history. But a new poll just released by the foundation found that 51% of respondents have an unfavorable opinion of the law, up from 46% in the March survey.

In the coming election campaign, Democrats are expected to highlight such provisions, including a mandate that insurance companies issue coverage for children even if they have pre-existing medical conditions.

"The few policies that aren't loved, such as the individual requirement to purchase insurance, make the overwhelmingly desirable provisions, such as the insurance-reform protections, workable and affordable," said Chris Jennings, a former senior health adviser to President Bill Clinton.

Another potential problem: The Congressional Budget Office initially found that the law narrowed the deficit, thanks to its tax increases and Medicare cuts. Opponents say such savings are illusory because they expect Congress to put off those provisions. Even so, reconciliation rules require Republicans to provide offsetting cuts.

When the health care overhaul passed in 2010, CBO calculated it would reduce the deficit by $124 billion over 10 years. Since then, the Obama administration has shelved the law's long-term-care insurance program, which CBO originally estimated would save $70 billion over that time period.

CBO declined to comment on future projections.

Proponents of repeal point out that the law's deficit-reduction projections are likely to diminish substantially by 2013.

Conor Sweeney, a spokesman for House Budget Chairman Paul Ryan (R., Wis.), said analysts used gimmicks to arrive at their original estimates for the overhaul's deficit reduction, and that the demise of the long-term-care program leaves a more manageable budget gap to fill.

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Republican presidential hopeful Mitt Romney.In the Republican-controlled House, Mr. Ryan has led efforts to repeal the legislation in its entirety. He has said he believes it can be replaced with other measures that would contain the cost of health care, such as changes to the structures of Medicare and Medicaid. He also wants to keep insurance companies from being able to deny coverage based on a person's medical history.

Choking off the law's funds, which some Republicans recommend, could help thwart the overhaul in 2013. But it would leave the law on the books for Democrats to revive funding for it in the future.

In the Senate, where the procedural problems are most acute, Sen. Orrin Hatch of Utah, the top Republican on the Senate Finance Committee, is pushing smaller bills to address specific pieces of the law, including requirements for individuals and employers to purchase insurance or pay a fine, and a tax on medical devices, according to spokeswoman Julia Lawless.

James Capretta, a top budget official in the administration of George W. Bush, said if drafters were "creative" and went after every provision that had spending implications, they could remove most of the law or make it irrelevant using the budget reconciliation process. "It would take a fair amount of work, but it's definitely doable," he said.

Senior GOP leadership aides said it was too early to know for sure how they would go about using the reconciliation process, and neither they nor the presidential candidates have specified how they would plug the budget gap.

GOP Wastes Obamacare Opportunity by Michael D. Tannerfrom Cato Recent Op-eds A new poll released last week shows that support for Obamacare has reached an all-time low. According to the poll by the Kaiser Family Foundation, which has traditionally found more support for the health-care law than other groups, just 34 percent of Americans now support the law. In fact, barely half of Democrats support the signature achievement of a Democratic president.

It's not hard to see why. Among the revelations in recent weeks:

Insurance premiums are rising. President Obama once promised that the health-care bill would save each of us as much as $2,500 annually on our premiums. But a recent survey by the Kaiser Family Foundation shows family premiums increasing by a whopping 9 percent this year, three times more than the previous year's increase. The average family policy now costs more than $15,000 per year. Not only has Obamacare failed to slow premium growth, but at least two percentage points of that increase is directly attributable to the health-care law's provisions.

Consumers have fewer choices. Obamacare is driving insurance companies out of the market, meaning there will be less competition and fewer choices. Just last month, two health-insurance companies announced that they were leaving Florida's individual-insurance market because of provisions in the law, most notably the medical-loss-ratio requirement that insurers must spend at least 80 percent of premiums on medical care or give customers rebates. And in Iowa, Des Moinesâ€“based American Enterprise Group announced last week that it will also pull out of the individual major-medical-insurance market, making it the 13th company to pull out of some portion of Iowa's health-insurance business since June 2010.

More debt, fewer taxpayers. A new study from the Congressional Budget Office concluded that the subsidies in the bill will add $1.36 trillion to the national debt over the first seven years after the bill is fully implemented. And at a time when 47 percent of Americans already pay no income tax, the bill's tax credits will remove as many as 8.1 million more Americans from the tax rolls.

CLASS Act dies (sort of). And how can we forget that the administration itself had to announce it was pulling the plug on the CLASS Act, the bill's Ponzi-like long-term-care program? At the same time, however, the administration came out against any effort to actually repeal the program that they believe is actuarially unsound.

Yet Republicans have seemed strangely quiet about the issue of late. So much so, in fact, that the Washington Times was led to wonder if Republicans have "given up" on repeal. There certainly does not appear to be much evidence that Republicans are still making repeal a top priority. The House hasn't taken a vote on Obamacare since trying to change the bill's graduate-medical-education funding back in May. There isn't even an all-out effort to get behind a repeal of the CLASS Act, despite Democratic defections on the issue.

And the Republican presidential candidates have relatively little to say as well. This seems especially odd, given that any Republican not named Mitt Romney should be hammering on the issue almost daily. But lately there seems to be more attention paid to the nationality of Romney's gardener than to his continued defense of Romneycare.

As for Romney himself, if he hopes to persuade Republican voters that there is a difference between Obamacare and the Massachusetts health plan — and, more important, that he can be trusted to repeal Obamacare — he should be saying so very frequently and very loudly.

This is one of those times when good policy makes good politics. But Republicans seem content to blow this golden opportunity.

Michael Tanner is a senior fellow at the Cato Institute and coauthor of Leviathan on the Right: How Big-Government Conservatism Brought Down the Republican Revolution.

Republican's ability to snatch defeat from victory can be frightening indeed.

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This week President Obama finally confronted a major U.S. health-care disgrace—the growing shortages of lifesaving drugs, especially anticancer therapies. For some reason the White House lumped its executive order with its "we can't wait" campaign against House Republicans, but the pity is that we will have to wait, because the only genuine fix is a liberal anathema: market prices.

Shortages have more than tripled since 2005, according to the University of Utah's Drug Information Service, and by the end of the year more than 300 products are likely to be back-ordered, in short supply or totally unavailable. Some are anesthetics and pain therapies, others emergency room "crash cart" drugs. But most—about 70% in 2010—belong to the class of drugs known as "sterile injectables" that are mainstays of the chemotherapy arsenal, such as paclitaxel or cytarabine.

The result is that more and more patients are receiving substandard care—relying on less effective or more expensive substitutes or else forced to postpone treatment. In oncology, delays of weeks or even days can be fatal.

Most sterile injectables have been off-patent for decades, but unlike other cheap generic drugs with low profit margins, production is complex and requires special facilities. Nonetheless, George W. Bush and the Republican majority decided that Medicare was "overpaying" for these cancer drugs and included a 6% cap on price increases every six months in the 2003 prescription drug bill. These new price controls (which apply to the providers that purchase the drugs) took effect in 2005, when the shortages began.

In a rational market, sterile injectable prices would now be rising to encourage more supply, since the demand for cancer drugs is inelastic. The old reimbursement system, called "buy and bill," was imperfect, but at least it allowed prices to float and wasn't producing the scarcity that central planning always does. The sterile injectables that are in short supply currently sell for $37.88 a dose on average, and modest price increases could make the market economic.

The problem is compounded because Food and Drug Administration rules cause pointless delays. It takes as long as two and a half years to receive FDA manufacturing approval for a generic, so other drug makers can't ramp up production if a company cancels a product line due to these disincentives or even if the fragile supply chain for sterile injectables is contaminated and manufacture is delayed.

Mr. Obama's executive order will do little if any good since it doesn't address or even mention this underlying distortion that Medicare has created. Instead, it merely expands the FDA reporting requirements about production interruptions or terminations. This is supposed to be an early warning system, but the scandal is that the availability of basic medicines could be allowed to become an emergency.

The order also tells the Justice Department to crack down on the "grey markets" that have sprung up to deliver supplies to doctors and hospitals, albeit with the inevitable markups. So rather than allow price signals to govern supply and demand, Mr. Obama wants to suppress them further.

The larger danger apart from the risks to the patients forced to receive compromised treatment is to the future of cancer progress. The common chemotherapy drugs are critical in clinical trials as the standard regimen or in combination with new options, and the Coalition of Cancer Cooperative Groups reports that as many as half of all ongoing trials require the drugs that are vanishing. This is a delay that really is killing people.

It will be interesting to see what Bigdog says. The facts are different but my understanding was that Clarence Thomas was not unduly influenced by people he knows including his wife, nor would he recuse himself. Kagan I think was personally involved with this legislation, but I believe they are their own judge of conflict of interest and the decision to recuse. These questions remind us of why Presidential and Senatorial elections matter greatly.

Clearly the constitution authorizes all power with no limits (sarc.), it will be argued. They never really meant that 'the powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people', did they?

It will be argued in court that the mandate is really a tax even though it was argued explicitly on the congressional floor of debate and to the people that it is NOT a tax. I'm wondering if anyone who makes that duplicitous argument in front of the Supreme Court will be charged with Contempt, handcuffed and hauled out of there.

Can someone please explain why Social Security is mandatory, acceptable and constitutional, Medicare (seems to me like a national health care plan for seniors) is mandatory, acceptable and constitutional,but constitutional/legal questions still exist concerning a National Health Care plan?

Soc. security is a tax made legal by the 16th. The 'contract' to pay you later is non-binding on the goverment. Your s.s. statement always says estimate with an asterisk. It is not a mandate. I don't pay any. Just choose no income. What in that did you think in that is comparable to mandating that every citizen purchase of a private product from a private company?

Constitution haters today should do what income tax advocates did back then - pass a new amendment if you want to authorize a new power previously left to the states or to the people.

For years Social Security and Medicare have been saying that they're running out of money. But, until now, the date of insolvency was years away.

The just-released Social Security trustees report says that Medicare will be spending more than it brings in this year. In less than a decade, the system will have run through all of its savings and be incapable of paying bills.

Social Security is slightly better off. By 2037--about the same time as GenX and GenY will want to punch out of the working world--Social Security won't have the money to pay full benefits.

When the systems stop running surpluses -- that's now -- it's also bad for taxpayers because the government has borrowed all the money out of the so-called "trust fund" to finance current operations. When those I.O.U. have to be repaid, there is less money for roads, parks, the military and every other service the government provides.

First, if we are going to get along how about a little forum etiquette. To whoever wrote: "Doug - you ignored [my second point]..." after I answered your first point while you answered none of my points in two substantive posts on the subject... don't write things like that. You don't know if I was done writing or had other matters to attend to.

There is a logic string that I call 'and another thing', where the implication is made that a second point builds on the strength of the first point before establishing any validity in the first point. If you want your second point considered first, put it first. I deny the charge that I don't answer enough points made on this forum.-----I know less about Medicare than social security (one reason to wait until I got home to look things up and post) but it looks to me like it operates EXACTLY the same way as the Social Security Tax. If you think it is a "contribution" or an insurance policy and not a tax, try declaring income and not paying it! Had you answered points already made we would have a starting point to discuss that. Medicare is another component of the payroll tax package we used to call FICA. Medicare is a 2.9% tax on income/wages and it brings no direct benefit to the one paying it. It pays out to people 65 and older in the form of health care benefits. They don't ask the recipient how much they paid in, and if you are under 65 they don't give you Medicare health care benefits, except for the exceptions. The 'promise' that it will be there when you are 65 or older is non-binding on the government, just like Social Security. As with social security, that is because each new congress elected every two years has the power to end or change every program. If they did not have that power, it fails a test we used to call 'consent of the governed'.-----Schedule SE calculates the self employment tax which includes the Social Security and Medicare tax. http://www.irs.gov/pub/irs-pdf/f1040sse.pdf It is based on Schedule C - Business Income: http://www.irs.gov/pub/irs-pdf/f1040sc.pdf. Also Schedule F - Farm Income. The tax is .9235 x 15.3%, temporarily reduced to 13.3%. In other words the self employed pay double - BOTH the employee and employer halves of FICA tax. There is no FICA / SE tax on schedule B income (dividends), Schedule D income (Capital Gains) or Schedule E income (rental real estate).-----I did not say I never paid S.S. taxes, just that I don't currently receive wages or business income that applies to Schedules 'C' or 'SE'. Take my situation as hypothetical, it is not a mandate on all citizens so it is not at all the same as the health care mandate. (Repeating what was ignored) Medicare just like Social Security is a direct tax on income that is specifically authorized in the 16th amendment to the constitution: "Congress shall have power to lay and collect taxes on incomes". Where (repeating the ignored question) does the constitution expressly authorize the power of congress to impose in ObamaCare a mandate to buy a private product?? If it is "not delegated to the United States by the Constitution" then it is "reserved to the states and to the people" - meaning it is NOT A FEDERAL POWER.

A better analogy would have been auto liability insurance except that it is not imposed on everyone and this has been extensively argued in courts. It is a choice to drive, and that mandate for drivers on public streets is a power reserved to the states and to the people. In the Obamacare case, it is 26 states suing the federal government for usurping their power. The majority of states say it is a power reserved to states, yet you deny there is a question, not just disagree with the answer.

Repeating my other question, when did we quit acknowledging the need to AMEND the constitution in order to create a new federal power. If you can't point to the authority for a power granted in the constitution, then just tell us you no longer live in a constitutionally based, limited government Republic. Maybe you are right.

On the merits, Doug's analysis seem well reasoned to me.=======================By JONATHAN H. ADLER AND MICHAEL F. CANNON Even if ObamaCare survives Supreme Court scrutiny next spring, its trials will be far from over. That's because the law has a major glitch that threatens its basic functioning. It's so problematic, in fact, that the Obama administration is now brazenly trying to rewrite the law without involving Congress.

The Patient Protection and Affordable Care Act offers "premium assistance"—tax credits and subsidies—to households purchasing coverage through new health-insurance exchanges. This assistance was designed to hide a portion of the law's cost to individuals by reducing the premium hikes that individuals will face after ObamaCare goes into effect in 2014. (If consumers face the law's full cost, support for repeal will grow.)

The law encourages states to create health-insurance exchanges, but it permits Washington to create them if states decline. So far, only 17 states have passed legislation to create an exchange.

This is where the glitch comes in: ObamaCare authorizes premium assistance in state-run exchanges (Section 1311) but not federal ones (Section 1321). In other words, states that refuse to create an exchange can block much of ObamaCare's spending and practically force Congress to reopen the law for revisions.

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CloseGetty Images .The Obama administration wants to avoid that legislative debacle, so this summer it proposed an IRS rule to offer premium assistance in all exchanges "whether established under section 1311 or 1321." On Nov. 17 the IRS will hold a public hearing on that proposal. According to a Treasury Department spokeswoman, the administration is "confident" that offering premium assistance where Congress has not authorized it "is consistent with the intent of the law and our ability to interpret and implement it."

Such confidence is misplaced. The text of the law is perfectly clear. And without congressional authorization, the IRS lacks the power to dispense tax credits or spend money.

What about congressional intent? Law professor Timothy Jost suggests that since ObamaCare requires all exchanges to report information about premium assistance, and it would be silly to impose that requirement on federal exchanges if their enrollees were not eligible, that shows Congress could not have intended anything but to provide assistance in federal exchanges. At least, he argues, there's enough ambiguity here about Congress's intent that federal courts will permit the administration to resolve it.

Not so fast. The Supreme Court has increasingly limited such deference to cases where the text of the law—rather than Congress's intent—is ambiguous. In this case the language of the law is clear, as even Mr. Jost admits.

The health law's authors in Congress deliberately chose to pass the bill with known imperfections and to use the reconciliation process to make only limited amendments. Writing a perfect bill would have required too many votes and risked failure. If what they passed was an imperfect bill with no premium assistance in federal exchanges, then that is what Congress intended.

And there are plausible reasons why Congress may have wanted to limit assistance to state-run exchanges—including encouraging states to create exchanges so that the federal government doesn't have the burden.

Supporters of ObamaCare, including George Washington University's Sarah Rosenbaum, have argued that nobody will have standing to challenge the IRS rule in court. That's not the case.

Under the law, employers must pay penalties when their employees receive premium assistance—a measure designed to encourage employers to keep offering coverage. Any employer whose employees receive premium assistance through a federal exchange would therefore suffer harm from the IRS rule and would have standing to challenge these illegal tax credits and outlays.

Public-interest lawyers could file suit as soon as the IRS rule becomes final and they find an employer that will be harmed. Any firm that doesn't offer health benefits and that employs lots of full-time, low-skilled, young workers in a state that fails to create an exchange should suffice. A successful challenge would block the law's employer mandate in that state.

In addition, under the Congressional Review Act, a simple (filibuster-proof) majority vote in each chamber of Congress could send to President Obama's desk a resolution blocking this IRS rule. Even if Mr. Obama vetoed the resolution (taking personal responsibility for this assault on the rule of law), a future president could still rescind the rule. Quite a perilous situation in which to leave the president's signature accomplishment.

Like the rest of the nation, the Obama administration wants a different health-care law than the one we got. But that doesn't give it the authority to rewrite the law by fiat.

Mr. Adler is professor of law and director of the Center for Business Law and Regulation at Case Western Reserve University. Mr. Cannon is director of health policy studies at the Cato Institute.

Doug did give you Crafty, per your request, a good explanation of the individual tax ramifications.

I never said Doug "never" paid S.S. taxes. However, Doug did say, "I don't pay any (S.S. taxes)."

As for Social Security and Medicare being only a "promise" not an obligation, perhaps, but I have no doubt it is a promise the country will keep withcertain necessary modifications. If that were to change, there would definitely be a "new Congress".

As for it's constitutionality, quite a few courts have said that it it; I suppose we will see, but the odds are in it's favor.I think many of the rulings and logic have been posted on this forum.

However for Doug to attack Obama Care because it allows private choice seems rather ingenious. Using Doug's logic, if Obama hadsimply proposed covering all American's through Medicare and taxed then accordingly that would be constitutionally ok, but mandating and giving them a choice of private products is not.

Well, maybe as I said, that is what he should have done. Most people are happy with Medicare. So let's just forgetthe private insurance choices. Think of all the lobbyists who would be out of a job.

From an actuarial standpoint (as I have previously mentioned, I spent years in the Health Industry) the more individual "choice"you have, the more adverse selection comes into play. That is one main reason group plans are able to offer favorable rates and benefitsversus individual plans. Worse, actuarially speaking, if someone can opt out, but later if they become sick or injured we still have a moral obligationto care for them. Unlike driving a car (you can walk, take the bus or metro) often times you have no choice when it comes to Medical Care.So we pay one way or another.

The point of 'Social Security and Medicare being only a "promise" not an obligation' had to do with the constitutionality question relating to the health care issue not the desirability of social security or a prediction of what future congresses might do. It is constitutional because in law it is merely another tax and another social spending program as legal as all the others. The 'social contract' is like the lockbox. It doesn't exist in law.

"...attack Obama Care because it allows private choice..." It restricts private choice. My previous coverage is already gone. In the name of reducing costs it makes it unlawful to simply choose fee for service, the way we pay for almost everything else and the best way known to control costs. Central to economics, supply and demand, is that suppliers can only charge what the consumers can afford and choose to pay. Turn over the payment system to an apparatus willing to spend without limit a trillion a year more than they take in eliminates all freedom based forms of price constraint.

"if Obama had simply proposed covering all American's through Medicare and taxed then accordingly that would be constitutionally ok"

Pres. Obama already said he preferred that and considered this a step along the way to getting there. But if he stuck to that in his campaign he would not have been elected by his own calculation. He also needed the votes in congress; even among Democrats the votes were not there. Constitutionally based on precedent, you are on the right track. Taxes to no end, unevenly applied, and government not regulating but participating in the health care services industry follows the precedent of what some consider to be wrongly decided cases.

"From an actuarial standpoint...the more individual "choice" you have, the more adverse selection comes into play. "

There were some far reaching Republican proposals on the table addressing pre-existing conditions etc. when Obamacare was passed. Water over the dam now, unless we get to start this debate again. These might have been considered regulating interstate commerce.

"I think there are valid points on both sides of the argument."

Thank you, that is quite a step forward from denying that a constitutional question even exists.

Case law has set the precedent implying that incremental increases in federal government power can expand forever without limit because of pronouncements like you quoted: "Congress can intervene in local, individual decisions when necessary to support a legitimate regulatory regime for interstate commerce". That thinking will win at least 4 votes from this court. Some of the others I expect will recognize this as a new power and they will have to decide what to do about that. What govt powers don't somehow relate to regulating interstate commerce in a global economy?

Pretty obvious to me though that it is not a "legitimate regulatory regime" to make it unlawful for an individual to choose fee for service over insurance products in a free society. It is a wholly different question from whether they can tax and/or provide social services. As I wrote 2 years ago, the vote will be 4-4 and the future direction of our republic will come down to the mood of one Justice Kennedy.

As we await the decision, one question remains for the power already exists crowd, what power then would NOT be legitimate for the federal government in your view? My view is that this if found to be constitutional, this could be their final case. We will no longer need to review federal powers.

We all agree that the costs of health care going up around 10% is unsustainable. We will all go bankrupt. Berwick "sells" (using his own term) his vision for the rest of using catch phrases like "quality", "human right" etc.

He does admit in a disingenius way that of course we are going to ration but we should do it with our eyes open. He is covering up the fact that extending care to 40 million people will not lower costs and that the rest of us will in some way pikc up that tab and get less. My opinion is that he is trying to get us to socialized medicine with arguments that he can improve quality of care, save costs on needless tests, health IT, performance measures, reducing side effects, infection rates.

The most telling part of the interview is an example he uses of a test his own daughter's insurance refused to pay for. He says he is a pediatrician and he can assure us she "needed" this test. What he doesn't tell us is that insurers do not refuse tests out of the blue and not without their own data that is EXACTLY the kind of stuff CMS is planning for us. His excuse is when the private insurers refuses payment they do not say why. I can tell you they do have appeals processes and the processes do include the option of a review by another doctor. Additionally everyone knows they go by actuarial data to determine what to pay for or not. That is exactly what he is planning. In any case health care in the US is broken. But I don't want single payer we are all forced to be in Harvard policy makers control health care.

Some women who had cancer that was not well seen on mammogram has lobbied politicians to require that doctors inform them of their "dense" breasts which might lead to a missed early cancer because of the density obscuring the spot.

So without any medical evaluation of whether lierally chasing down every dense breast in the US leading to more expensive imaging tests and more procedures mostly false postives we have a political activist going straight to the poliiticians for more gigantic spending. Oh "but it will save lives and how much is a life worth" is the retort?

Folks there is no end in sight to do gooders. We are so F...!

****Dense Breast Bill Veto in Calif - Lets get on Jerry Brown's case!

Jennifer1961Posts: 130Joined: May 2010 October 13, 2011 - 11:22pm Hey ladies! I'm so upset about this veto. OUr legislature passed the bill which would require that women be informed of dense breast and that mammogram may not show malignant growths. I never thought this would happen or I would have put pressure on Jerry Brown. From what I understand he bowed to the Calif. Medical Assoc. which is a very powerful lobby here. I personally could have been spared a lot of grief if I had been told I had dense breasts. I had my mammogram faithfully every year, but no one thought to mention it to me. Perhaps it could have been caught sooner and I wouldn't of had to have chemo and 6 surgeries. But I'm lucky. My tumor was close to the surface so I was able to feel it pretty easily. I know a lot of ladies aren't so lucky and they end up with a dire prognosis. This is about $$$$ nothing else. Let's give Gov. Brown a piece of our minds. Let him know we're more powerful than the Calif. Medical Assoc.

Jennifer

‹ do not want to take anastrozole? CT scan, no changes, but 10th infection since April and this time in the kidneys ›

login or register to post comments kchaffeePosts: 4Joined: Oct 2011 October 20, 2011 - 12:45amHENDA LAWHenda Law. All women should be informed about their breast density andthe need for additional testing. Jerry Brown is allowing women to die,because he vetoed the law on this very issue, he has blood on his hands.

Lets start a Occupy Protest on this very important issue.............

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New FlowerPosts: 2583Joined: Aug 2009 October 21, 2011 - 10:07pmyes it is very important to be awareI wish I knew, probably could catch mine much earlierNew Flower

New FlowerPosts: 2583Joined: Aug 2009 October 24, 2011 - 8:50pmGood Thank youI still cannot understand the gov. He is proposing many other spending initiatives, while young women are suffering from misdiagnosis and likely to get treatment at the very late stage. Vicki, I am glad that you have been The content on this site is for informational purposes only. It is not a substitute for professional medical advice. Do not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

Democrats are running on Mediscare in 2012 and President Obama has all but called the "premium support" reform un-American, if not the decline and fall of Western civilization. That would seem to put the issue in Newt Gingrich's wheelhouse, but the GOP candidate also claimed in a recent interview that the Paul Ryan reform model is "politically impossible" and "suicide." Well, not so fast.

Today Senator Ron Wyden and Mr. Ryan are releasing a bipartisan defined-contribution health-care plan, as the Oregon Democrat and Wisconsin Republican explain nearby. This is an important moment because it shows that the serious entitlement debate is taking place within the camp of choice and incentives, not the Obama status quo.

Wyden-Ryan shares the same architecture as the House budget. It would replace today's open-ended Medicare with a fixed-dollar subsidy for seniors to choose from a menu of private plans. Costs would fall as insurers and providers innovate to compete for patient market share, rather than responding to fee-for-service price controls.

But there are several key changes. Most of the substantive argument turns on how the premium supports should grow over time. Wyden-Ryan would dispose of a predetermined rate—GDP plus 1%, medical inflation, etc.—and instead use competitive bidding. Insurers and traditional Medicare, which would remain intact, would essentially participate in a reverse auction and the second lowest bid would set the benchmark for a given region. Seniors would pay at the margin for more expensive options.

As a practical matter, competitive bidding may be an improvement over a set formula because it relies on local information and adjusts with the behavioral and organizational responses that will vary from region to region. Medicare as centrally planned from Washington will never be able to keep pace with the market if subject to the same defined payments. In any case, the growth rate to-and-fro is largely an artifact of the Congressional Budget Office, which has admitted there is a "gap in the toolkit" when predicting market-based savings. It knows this first hand from having grossly overestimated the costs of the 2003 prescription drug benefit.

Messrs. Wyden and Ryan also sneak in a reform of the larger employer market, which would allow businesses with fewer than 100 workers to move to a defined-contribution model without tax penalties. Mr. Wyden has been campaigning for such a reform for years from the Democratic backbenches.

The Oregonian voted for the Affordable Care Act, though his decision to join Mr. Ryan is another signal that the entitlement debate is moving in a more promising direction. Variations on defined contribution were also mulled by the "super committee," only to end up on the horns of liberal intransigence.

The brutal math is that Medicare spending has been growing about three percentage points faster every year than the overall economy for the last quarter-century and is now the main driver of the fiscal crisis. Mr. Obama has ruled out any structural reforms and his only fallback is the command-and-control technocracy that continues to fail and will ultimately harm patient care. The Wyden-Ryan deal shows that smart liberals prefer a different future.

By LOUISE RADNOFSKY The Obama administration said Friday it would shift to states the decision about what treatments many insurance plans must cover under the health-care overhaul, sidestepping contentious fights with Republican state officials and patient-advocacy groups.

The move—a departure from the way the administration had been expected to implement the provision—disappointed some disease-advocacy groups that had hoped federal regulators would spell out exactly what services insurance policies for millions of Americans will have to cover to be sold in state-run insurance exchanges that open in 2014.

Instead, the administration said states could use what is now offered in their local markets as the basis to determine what benefits must be included in new plans sold to individuals and small groups.

The move represents an attempt by the administration to defuse Republican criticism that the law gives the federal government too much control over Americans' medical care. But some small-business employers immediately raised concerns that the change would make plans more expensive for them.

States will be able to set their coverage standards to align with either those of the most popular federal-employee plans in the state; the most popular state-government employee plans; the largest plans offered to consumers who buy coverage in small groups, or the largest HMO in a state's market.

"As we've acknowledged many times, coverage that works in Florida may not work in Nebraska," said Health and Human Services Secretary Kathleen Sebelius.

Republicans and employer groups warned the approach could allow states to mandate a rich benefit package, particularly because the federal employees' health-benefits plan is among the country's more generous packages. The most popular national federal-employee plan offered by Blue Cross and Blue Shield typically covers some therapies for a person with autism, chiropractic services and infertility drugs, among other things.

Neil Trautwein, employee-benefits policy counsel at the National Retail Federation, said he was concerned the cost of a federal-employee plan could be beyond the reach of an individual purchaser or a small employer.

The approach also made some disease groups wary that their ailment could get left out of the final benefits requirements.

"It's not what we were asking for," said Carl Schmid, deputy executive director of the AIDS Institute. "I think it's very clever what they did, but I think that what patient groups were looking for was a list of mandated services. This is still going to allow a patchwork of care and that's what I thought we were going to try to get beyond."

Some larger patient-advocacy groups said they were optimistic that if states opt for the standards of the federal plan, it would be helpful for their members, though they were less sure about the impact of states picking the other benchmarks.

"People with cancer and their families have fared well under the largest federal employees' health-benefits plan," said Stephen Finan, senior director of policy at the American Cancer Society Cancer Action Network. "The quality of coverage patients receive under the three other options…is less certain."

Federal health officials said Friday they expected most of the options offered in the state exchanges to meet the wider coverage requirements outlined in the law. In some instances, they said, states might have to ensure their standards included rehabilitative and pediatric dental and vision services to comply with the measure.

The implementation plans also raise questions of possible disparity, with people in some states having better plans than others. And depending how substantive the coverage differences are among states, it could lead some people to move in an attempt to get better coverage elsewhere.

The move came in a "bulletin," which isn't binding but indicates the regulations the federal government is going to issue in the future.

Steve Larsen, a top HHS official in charge of enacting the overhaul law's insurance changes, said the bulletin was intended to help states plan ahead as they start new legislative sessions in January.

If a state refuses to set up an exchange, the federal government will run it for them. If this happens, the government will use one of the largest local small-group plans operating in the state to set standards for its exchange, officials said, an effort to be seen as committed to a market-based approach.

Many state governments are hostile to the overhaul law, and 26 have brought a case challenging its constitutionality, which will be decided by the Supreme Court next year.

Some of those states are simultaneously taking steps to implement the law locally, including setting up exchanges. Many governors in those places argue that it is preferable to retain as much state control over how the law is operating in their state if it is upheld.

Way back on the Federal Page of today’s Washington Post is an article that ought to be on the front page above the fold, and its deep placement on the boutique page of the bureaucracy shows how the Post, like most everyone else, doesn’t understand what a big story it is. And it is clinical study of Hayek’s “knowledge problem”—the impossibility of centralizing fundamentally dispersed knowledge in a timely and accurate way—that we’ve discussed at various times here over the past few months.

The headline is “Concern growing over deadlines for health care exchanges,” and it discusses the difficulties of one of the main pillars of Obamacare—the mandate that the states set up insurance “exchanges” where people and businesses can do one-stop shopping for their mandated health insurance policies. But this is no simple exchange; because of the mix of federal programs such as Medicaid and Medicare, and the various regulations pertaining to eligibility, guaranteed issue, and other features of Obamacare, the states are having a hard time figuring out how they are going to do it. And time is running out. As the Post explains, “the exchanges will need to incorporate state and federal data on income, employment and residency. Enrollment through the state and federal exchanges is scheduled to begin in the fall of 2013.”

Obamacare has a fallback position: if states can’t (or won’t) make the deadline, the federal government will step in and run the exchange out of Washington. I’ve heard rumors for months now that the Dept. of Health and Human Services is terrified of having to do this, and doubts it can be done by the deadline. The Post story would seem to lend some credence to these rumors:

It’s hard to know how far along the federal government is because the Obama administration has “been very reluctant to provide any updates on progress,” said Dan Schuyler, a director at the consulting firm Leavitt Partners in Salt Lake City, which is advising states on the exchanges.

The Department of Health and Human Services did not respond to requests for comment. Those designing a federal exchange face enormous technical, political and financial challenges.

Technically, data from a host of federal agencies need to be collected into one system, which then must be linked with computer systems in 50 states and the District of Columbia.

Matt Salo, executive director of the National Association of State Medicaid Directors, said computer systems in some states are old and may need substantial upgrading. There is some doubt, he said, about whether there is enough “physical capacity in the IT systems world” to get it all done in time.

All the extremely private health care individual information in the nation integrated into one easily accessed system. What could possibly go wrong?

A trick question from my early career in bank information systems: what is the objective of the bank's computer system? It is a rookie mistake is to think the system should make all information available to all users. The answer is the opposite. The system needs to hold and process all the data with people's very private information but only make very limited information available to any user - just enough to do their job with proper security clearance. The larger the institution, the larger the opportunity for security breaches. Has anyone ever heard of wikileaks?

"Spending on Medicaid, a theoretically cooperative federal-state program, isapproximately 40 percent of all federal funds given to states and 7 percent of allfederal spending. Enacted in 1965 as a program for the poor, it has exploded. Theincrease in its costs by the end of this decade is expected to be $434 billion. ...Obamacare requires states to cover all persons with incomes up to, effectively, 138percent of the poverty level. The federal government will pay all increased costs(other than administrative costs) until 2016; by 2020 states will pay 10 percent ofthe expansion. But even with the federal government paying most of the costs, inmany states their portion of Medicaid costs is the largest item in their budgets,even exceeding education. And Obamacare, which forbids states to make morerestrictive the eligibility criteria it adopted before this new burden, would denyall Medicaid funds to noncompliant states. This would cost most states billions ofdollars. ... In theory, state participation in Medicaid is voluntary; practically,no state can leave Medicaid because ... [it] leaves states this agonizing choice:Allow expanded Medicaid to devastate your budgets, or abandon the poor." --columnistGeorge Will(http://patriotpost.us/opinion/george-will/2012/01/22/something-to-argue-about/ )

A couple of months back, I was with a friend of mine when she suddenly collapsed and I found myself having to run her to the emergency room. After a fairly harrowing 14 hours, the hospital released her, the doctor writing her a prescription for the still-very-intense pain she was in. So we stopped at her local Kinney Drugs in Vermont.

Despite having been called in by the doc, the prescription wasn't ready. Come back in an hour. Heigh-ho. So we left it an hour and a half, and then, not wishing to make another pointless trip, called the pharmacy just to make sure. No, sorry, the druggist said. They ran the insurance number and it was denied. So they canceled the prescription. Without calling the patient to tell her they'd canceled it. I passed the phone to my friend, lying on the couch like a tubercular Victorian heroine, and she explained that her employer had recently switched plans from Blue Cross/Blue Shield to Cigna and, midst groans, gave them the new policy number. She waited another hour in pain and we then returned to Kinney Drugs, using the convenient drive-thru lane.

This time, they had the drugs. My pal handed over her new insurance card. After some 15 minutes, the clerk returned and said the insurer had declined it. There were two cars backed up behind us. My friend said that couldn't be right, the number was valid, could they please run the number again. They did. Same result. There were now four cars behind us. The clerk suggested we drive around the building, join the back of the drive-thru line, and maybe when she'd taken care of the four cars behind things would have quietened down sufficiently for her to call someone and try to find out what the problem was.

Never mind my friend's crippling pain, spare a thought for me: I'd had to spend untold hours being kindly and supportive and sympathetic, which is not a role to which I'm naturally suited, and the strain was beginning to tell. In that useful Americanism, I didn't need this in my life right now. So I enquired of Kinney Drugs whether it would be possible for us just to pay for the prescription — you know, with money — and then bugger off to resume our lives. She went off to see whether that was still possible. Upon her return, I grabbed my wallet and pulled out a credit card.

"That will be eighteen dollars and 79 cents," she said.

Oh. For whatever reason — perhaps the sheer dogged determination required to negotiate this time-consuming transaction to a successful conclusion — I had assumed this would be one of those expensive pills about which one hears so much and I'd be ponying up 500 bucks. Instead, I put away the credit card and fished out a $20 bill.

And then I thought of the opportunity cost not only to me but to the four cars behind. It seemed a very expensive way to buy 18 bucks' worth of pills.

It turned out my friend's prescription was denied because someone at the pharmacy had transposed two numbers. Oh, well. Could happen to anyone. And, in fact, it does. Speaking as an unassimilated foreigner, I notice when you're standing in line that the big difference between a trip to the pharmacy in the U.S. and one in the rest of the developed world is that in America the druggists spend virtually their entire time talking about not the medicine but the "customer"'s degree of access to it. For example, while guest-hosting for Fox News just after Christmas, I was taken ill while in New York. Saw a doc, got a prescription, this time went to a Duane Reade pharmacy on Sixth Avenue. The lady ahead of me was going away for New Year's. Too bad. Her health-care provider declined to provide her with a renewal of her prescriptions before the 31st. The stylishly accoutered lady ahead of her had a better strike rate. After some delay, the pharmacist returned. She informed her (and the rest of us) that the good news was that her insurer had approved her Ortho, but the bad news was that they'd denied her Valtrex. Ortho is a birth-control pill. Valtrex is a herpes medication. Had her dinner date been a couple of places behind me in line, the news might have cast a bit of a damper on his evening. As it was, it occasioned general amusement among the women present.

I don't quite know what you'd call these rituals, but the term "private health-care system" doesn't seem the most obvious fit. Indeed, as in so many other areas of American life — the Fannie-Freddied mortgage market, the six-figure college education — the main purpose of these dysfunctional labyrinths ever more disconnected from any genuinely free market seems to be to discredit the very concept of a "private" system and thus soften up the electorate for statist fixes. I've argued for years in these pages that governmentalized health care fundamentally transforms the relationship between citizen and state in ways that make it all but impossible to have genuinely conservative government ever again. But at least the Canadian and British systems have the saving grace of an equality of awfulness. Both Obamacare and, alas, Romneycare seem designed to combine the worst aspects of the Scottish NHS and America's present third-party pseudo-market — and thus a scale of bloated, bureaucratic, inflationary capriciousness unknown to human history.

In free, functioning societies, it ought to be easy to buy a bottle of pills. The fact that it isn't is one reason why America has a real bad headache.

The Foundation"Tyranny, like hell, is not easily conquered; yet we have this consolation with us, that the harder the conflict, the more glorious the triumph." --Thomas PaineGovernment & PoliticsObamaCare's Continued Chaos

To no thinking person's surprise, the Obama administration admitted this week that another element of ObamaCare is going to cost more than originally expected. This isn't really news so much as it is yet another confirmation that the president's takeover of health care will be an absolute disaster.The latest program to exceed expectations is the Pre-Existing Condition Insurance Plan, which provides health insurance for people who can't obtain coverage through private carriers. The PCIP was meant to be an interim program phasing out in 2014, at which point all insurers will be required to accept all comers who want coverage. In November 2010, the federal government estimated an annual cost of $13,000 per enrollee. Since the program's launch last year, some 50,000 people have signed up, and now the expected cost is around $29,000 per enrollee.While we're on the subject, the outrageous contraception mandate remains yet another tarnished gem in the ObamaCare crown. Health and Human Services Secretary Kathleen Sebelius announced this week that the administration has begun "outreach" to officials in the Catholic Church, insurers and groups that run self-insured insurance plans. However, Sebelius' "outreach" isn't in search of a compromise with faith-based groups whose rights are being trampled for the sake of free contraception. The administration hasn't backed down from its non-compromise offer that the cost for free contraception be shifted from faith-based employers to private insurance companies. The mandate is here to stay, and faith-based employers have 18 months to comply.One of the free contraception mandate's more vocal supporters testified this week before the House Democratic Steering and Policy Committee about how tough life can be without free birth control. The hearing was nothing more than a showpiece for the issue with a single witness, Sandra Fluke (is there a pun here?), a Georgetown law student and self-professed "reproductive rights activist." Fluke made the absurd claim that free contraception is a necessity at her school, which currently doesn't provide it. "Forty percent of the female students at Georgetown Law reported to us that they struggled financially as a result of this policy," she complained. Of course, the HHS mandate has nothing to do with university students, but that's beside her point.Fluke asserted that contraception could cost $3,000 through three years of law school. That's a lot of money to spend on protected sex over that time frame. In fact, humorist Frank J. Fleming quipped, "Anyone buying that much contraception should probably be writing it off on her taxes as a business expense." Fluke's assertion that she and other women have an absolute right to contraception at someone else's expense is disturbing. There is no right to sex free of consequences. Fluke also implies that the women of Georgetown law have no control over their urges or actions, all the while thinking she's standing up for women's rights. When did "get your laws off my body" become "you have to pay for the stuff that goes into my body"?The most important question, of course, is just where within the Constitution is the government granted the power to mandate this sort of thing for private or religious organizations? This was asked of Rep. Kathy Hochul (D-NY) by one of her constituents at a recent town hall. She replied, "Well, basically, we're not looking to the Constitution on that aspect of it." We suppose Hochul's candor is refreshing, but it didn't sit well with the crowd -- nor should it. Hochul attempted to defend ObamaCare by stating that Congress determined that citizens are entitled to health care. "So why don't we provide free access to Band-Aids and cancer screenings?" the constituent followed up. "Aren't those more important to health care than contraception?" Hochul could only say, "Well, clearly more work needs to be done." Nice understatement.In the Senate, an amendment to impose a religious-conscience exemption to ObamaCare was rejected Thursday. Proposed by Sen. Roy Blunt (R-MO), the Respect for Rights of Conscience Act was attached to an upcoming transportation bill. Democrats were nearly united in opposition, and retiring Maine "Republican" Olympia Snowe was the only GOP member to oppose it. Obama, adamantly pushing "free" contraception, would have been forced to veto the whole transportation bill in order to prevent the conscience exemption from again being the law. His other option would have been to let the amendment pass and hope it takes some of the heat off as the presidential election moves forward.The one bit of good news is that a House committee voted to throw out the "death panel" provision of ObamaCare. The Independent Payment Advisory Board was supposed to help with cost control, but has been accurately tagged as a "death panel" because of its rationing of care. All things considered, however, a new administration and a more Liberty-friendly Congress must be installed in January to repeal this monstrosity.

From an actuarial standpoint, paying for contraceptives is far more cost effective than pregnancy. It's cost effective; consider it preventative medicine. Or are you suggesting that pregnancy, a voluntary optional procedure not be covered like it wasn't under many plans years ago?

From an actuarial standpoint, paying for contraceptives is far more cost effective than pregnancy. It's cost effective; consider it preventative medicine. Or are you suggesting that pregnancy, a voluntary optional procedure not be covered like it wasn't under many plans years ago?

This is the role of government? How about we just sterilize those who can't afford birth control? That's even more cost effective, right?

Good grief GM; do you know anything about actuarial science or employee benefit plan design? Incentives?

All those tests you get for free in your health care plan, your physical, immunizations, etc. Do you think they do that because they are nice? Of course not,routine care, preventative care is cheaper than expensive procedures. I don't know if it's the role of government or not, but if you want to have a cost effective plan you need to provide carrots and sticks. Or just pay and pay and pay.

It's your choice; no one is making you do anything. But they offer an incentive, i.e. free for contraceptives. That is a whole lot cheaper than pregnancy.

A March 31 AP article entitled “Sebelius calls for action now on health care” repeats the claim, pushed by proponents of government run health care, that there are “48 million uninsured Americans”.

Numbers in the 40-million range regularly used by proponents of health care “reform” are based on reports from the Census Bureau which show, for example, over 45 million people “not covered” in 2007. However, these numbers are extremely misleading for several reasons, and the difference is critical not simply as a debating point but as a context for appropriate government policy changes. ■The Census Bureau itself says that “Health insurance coverage is likely to be underreported…” (See Appendix C of THIS report) For example, “16.9 percent of people with an MSIS record indicating Medicaid coverage reported…that they were uninsured.” ■According to Sally Pipes of the Pacific Research Institute, “as many as 12 million uninsured Americans are eligible for Medicaid and the State Children’s Health Insurance Program–but they haven’t signed up.” ■More than half of the uninsured are between 18 and 34 years of age, a group which has relatively few expensive health issues and for whom self-insuring (paying their own medical bills) makes sense. Only 14% of people over the age of 55% are uninsured. ■Over 9 million of the “uninsured” have household incomes over $75,000. ■Roughly 30% of the uninsured are without insurance for less than 6 months (though this statistic will likely worsen during the current recession). ■And finally, estimates are that between 7.5 million to over 10 million of the uninsured (15% of them or more) are illegal immigrants.

The number of chronically uninsured people who would prefer to have insurance but can’t afford it is likely 10-12 million people, or one quarter of the number often repeated by the media. Reporters who cite the 48 million number without providing a full context do their readers a great disservice.

"The number of chronically uninsured people who would prefer to have insurance but can’t afford it is likely 10-12 million people"

Yes, out of 310 million people. Other proposals on the table as alternatives to Obamacare including end of pre-existing conditions clauses, tort reform and allowing cross state line competition would have shrunk the 10 million figure significantly.

'Can't afford it' is a function of two variables: income and cost of health care. One party's policies have the effect of lowering national income or at least stopping its growth, while implementing hundreds and huindreds of programs that drive up the cost of health care. The other party is struggling within itself to decide how large the (negative0 role of government should be.

Dany Mercado, a leukemia patient from Kitchener, Ontario, is cancer-free after getting a bone marrow transplant at the Barbara Ann Karmanos Cancer Institute in Detroit.

Told by Canadian doctors in 2007 he couldn't have the procedure there, Mercado's family and doctor appealed to Ontario health officials, who agreed to let him have the transplant in Detroit in January 2008.

The Karmanos Institute is one of several Detroit health facilities that care for Canadians needing services not widely available in Canada.

Canada, for example, has waiting times for bariatric procedures to combat obesity that can stretch to more than five years, according to a June report in the Canadian Journal of Surgery.

As a result, the Ontario Ministry of Health and Long-Term Care in April designated 13 U.S. hospitals, including five in Michigan and one more with a tentative designation, to perform bariatric surgery for Canadians.

Yes, Canada and Rest of the World benefited from the advances and care available that came out of what freedoms we had left in our healthcare system.

Rule One in economics: tax something and you will get less of it.

Rule One in Obamanomics: New excise tax on medical devices.

I had a discussion last week with a person who is head of strategy for a major medical device manufacturer. I did not know the person's politics but asked if the new tax on their product would be helpful to them. The answer was No.

Killing off the medical device industry here hurts people everywhere.-----------------

Last week, the IRS released its proposed plan to implement the 2.3 percent excise tax on medical devices designed to help foot the bill for Obamacare.

Harmful effects of the health law’s new taxes and requirements on business continue to emerge as its implementation continues. As Heritage’s Curtis Dubay explains, “All tax increases have negative economic effects because higher taxes take resources from the productive hands of the private sector and transfer them to the wasteful hands of politicians.”

As the National Center for Policy Analysis shows, the medical device manufacturer tax is already hurting Americans by reducing employment:

In November 2011, device maker Stryker Corporation announced its intention to layoff 1,000 workers in order to cut costs in advance of the tax.

Another firm, Covidien Plc, announced the layoff of 200 U.S. workers and plans to offshore production to Mexico and Costa Rica.

Congress can legislate who collects a tax, but it cannot legislate who actually bears the tax’s economic burden. So it is surprising only to Congress that American workers have to bear the brunt of a tax that Congress assumed device manufacturers would pay.

Proliferation of unneeded and redundant Medical Devices on every corner is just one of the reasons our Healthcare system is out of control.......

latimes.com

Worldwide price survey puts U.S. medical, hospital costs at top

By Patrick McMahon

4:50 PM PST, March 6, 2012

A study comparing prices for hospital stays, physician office visits, drugs and other medical procedures in developed countries shows U.S. prices among the most expensive.

The International Federation of Health Plans, a London-based network of 100 insurance companies in 30 developed nations, annually looks at prices, and last week published its 2011 Comparative Price Report on medical and hospital fees by country.

Among the results: Cost per day for hospital charges averaged $3,949 in the U.S., followed by Chile at $1,552. The average hospital cost for a U.S. patient’s total stay was $15,734; Germany was next at $5,004.

For appendectomies, the total facility and physician costs averaged $13,003 in the U.S., followed by Switzerland at $5,840.

A physician fee for a routine office visit averaged $89 in the U.S., also followed by Switzerland, at $64.

U.S. was second on the list for total facility and physician costs for cataract surgery, averaging $3,748. Switzerland led the list at $5,310; Australia was No. 3 at $3,591.

Scott Hauge, president of the San Francisco-based Small Business Coalition, told coalition members this week that the survey and other indicators of growing medical costs are "not good news for small businesses that are struggling to continue to provide health insurance and why health insurance access and cost is the number one issue again for small businesses in our survey."

"Proliferation of unneeded and redundant Medical Devices on every corner is just one of the reasons our Healthcare system is out of control......."

Good grief, what does that mean? Will the new medical device excise tax help us to quash these cures gone wild?

I wasn't clear; I have no idea why they were implemented, nor do I support any new tax on medical devices.

"Cost per day for hospital charges averaged $3,949 in the U.S."

Costs are higher than people can afford because of THIRD PARTY PAY.

That's not quite true. You posted on another thread, "There is something about the concept of insurance the activists don't understand. You insure against expenses uncertain or unforeseen, the regular bills you simply pay. " I agree; I am not rich, but i have a $5K deductible insurance plan. As you said, I can budget for the routine, but not the unexpected. It's like my car insurance; again I have a high deductible.

That said, I've used my car insurance carrier before. I've also used, even recently my health insurance. And many people's financial pain threshold is less than $5K. Third Party Pay is here to stay. But that's good; they act as a funnel, a filter actually in many instances reducing costs.

Necessary medical care is almost unique. If I'm in a motorcycle accident, I break my ribs, injure my knee, and have a concussion, when the ambulance arrives, I'm not going to ask the price. Nor would I ask the price at the ER room since I'm in pain. I have no choice. Almost any other product or service I can think of allows me to shop and price compare. Or simply not buy, like not buying a car and choosing alternatives. So that makes medicine unique.

My point about medical devices is given our free enterprise system, every tiny hospital, every tiny clinic seems to want the latest and best. But they don't need it; there is an MRI down the street; why does each town need a surplus of them time whatever multiplier? Because of Medical Device salesmen (no fault of theirs; that's their job) and the keeping up with the Jones attitude. It's cheaper to have big brother say you only need 5 MRI's not 15 for example. if you look at studies of procedures, doctors aren't stupid, they do the procedures that pay the most, not the ones that are the most cost effective. You need a third party, who is there to rein in greed because people will pay anything, do anything, because they are in pain or are dying. If you doctor says you need an MRI, are you going to say "No" or even get a second opinion? Of course not. The physician is "god" and you don't question "God". And so you go get an MRI at the facility in which the doctor has a financial interest. Or a friend. But definitely not the one that is the most cost effective.

You should be insuring only for the unexpected that you can't afford. That shares the cost with all the people taking the same or similar risks. We already have free health care for the poor, that is an old and tired argument.

"...But they don't need it; there is an MRI down the street; why does each town need a surplus of them time whatever multiplier? Because of Medical Device salesmen (no fault of theirs; that's their job) and the keeping up with the Jones attitude. It's cheaper to have big brother say you only need 5 MRI's not 15 for example."

Really? The only successful form of cost constraint is a free market loaded with competition. Granted healthcare will never be a free market, but that does not justify a full abandon all of what works for tyranny.

I don't know what it is you don't know about medical device sales, but it isn't that easy. The way you don't take unnecessary MRIs is to PAY FOR THEM. Do you leave the gas pump on when you leave or fill up on someone else's card, do you buy steaks at the grocery and leave them on the counter and not go back to get them, do you leave your credit card at the golf clubhouse after you charge your green fees and say charge the next several groups too or expect that someone did that for you. No. We tie usage to payment; it is quite simple. We watch our expenses like hawks when it is our money.

With a federal government running 40% of its expenses unpaid for before Obamacare, it is all a bunch of b*llsh*t to even think taxing the rich or the medical device company is paying for it. They won't and they don't. You should be criticizing the political salesmen who say someone else should pay for it when they know no one else is.

"I have no idea why they were implemented, nor do I support any new tax on medical devices."

They were pretending to pay for free health care, BCP for the sexually active, etc.

"If I'm in a motorcycle accident, I break my ribs, injure my knee, and have a concussion, when the ambulance arrives, I'm not going to ask the price. Nor would I ask the price at the ER room since I'm in pain. I have no choice...."

You are talking to the wrong guy. I've been hit by a car (hit and run) and when they finally came they asked me which hospital I wanted to be taken to. If there was one that had a reputation for higher quality or lower cost, I could have chosen.

Prices are high because of government mandates and third party pay more than any or all other reasons. Every other industry where these factors are smaller has the natural forces of cost control that are removed from healthcare. Please point out where this is not true.

The result that will come out of this is losing the right to ride the motorcycle. Why don't you see that? You have the freedom to ride and you have the freedom to insure your risk. Why do you need government to step in - in any way - and limit your choices?

"Third Party Pay is ... a filter actually in many instances reducing costs. "

Good grief. Payments funneled through insurance companies to chosen suppliers with bureaucratic decision makers... that is better than free people making free choices? Why not for all industries instead of just the most crucial ones? FYI, self insured, I was the only one out fixing houses the day after the tornado, half the rest the fully insured were in meetings and negotiations and half with their government mortgages and zero equity never did repair. God bless your right to vote and post anyway. I hope the viewpoint expressed is soundly defeated in November.

I don't know what it is you don't know about medical device sales, but it isn't that easy. The way you don't take unnecessary MRIs is to PAY FOR THEM. Do you leave the gas pump on when you leave or fill up on someone else's card, do you buy steaks at the grocery and leave them on the counter and not go back to get them, do you leave your credit card at the golf clubhouse after you charge your green fees and say charge the next several groups too or expect that someone did that for you. No. We tie usage to payment; it is quite simple. We watch our expenses like hawks when it is our money.

Maybe somehow I wasn't clear, but there is a huge difference (I don't have a choice; I must have treatment) between steaks and golf. That's the key; medical is not optional. Further, it's a mystery, i.e. we trust our doctor's opinion. I may respect your opinion on which steak to buy, or which club to use, but the repercussions of my ignoring your advice aren't fatal. It may well be with a medical decision.

"If I'm in a motorcycle accident, I break my ribs, injure my knee, and have a concussion, when the ambulance arrives, I'm not going to ask the price. Nor would I ask the price at the ER room since I'm in pain. I have no choice...."

You are talking to the wrong guy. I've been hit by a car (hit and run) and when they finally came they asked me which hospital I wanted to be taken to. If there was one that had a reputation for higher quality or lower cost, I could have chosen.

I did have a choice, although it wasn't put to me that way. I knew which hospital was better so I went there (they will take you to the closest one unless you insist). But again, medicine is different. I don't mind driving a low end car (5 year old Subaru), it get's me to and from just as good as my friend's Jag. But if I broke my leg, do I want the lowest cost, poorly trained doctor to set it? I mean I might be cripple for the rest of my life. Not to mention if my condition was life threatening. There is a huge difference needing, wanting, and a product that is an absolute necessity....

Prices are high because of government mandates and third party pay more than any or all other reasons. Every other industry where these factors are smaller has the natural forces of cost control that are removed from healthcare. Please point out where this is not true.

No you are right, 99% of the time, I would agree with your argument, but I repeat myself; Medical Care is unique. Please point out any other product with similar ramifications and pricing that will affect my life so dramatically.

The result that will come out of this is losing the right to ride the motorcycle. Why don't you see that? You have the freedom to ride and you have the freedom to insure your risk. Why do you need government to step in - in any way - and limit your choices?

No, that's not true. I don't care about the motorcycle. It's trash. I can buy another one (I've given up and gone to bicycles). Your theory only pertains to vehicle insurance. I again agree with you, if you can't afford the insurance and/or self insurance cost, don't drive; take the bus or walk. However, MEDICAL IS DIFFERENT. If I break both legs, I get cancer, etc. I can't choose to ignore the problem or choose an alternative or choose to do without, I MUST do whatever's necessary to solve the problem. And as a society, we IMHO cannot let anyone go without basic medical care. I don't want cripples on the street because they couldn't afford to have their leg set.

"Third Party Pay is ... a filter actually in many instances reducing costs. "

Good grief. Payments funneled through insurance companies to chosen suppliers with bureaucratic decision makers... that is better than free people making free choices? Why not for all industries instead of just the most crucial ones? FYI, self insured, I was the only one out fixing houses the day after the tornado, half the rest the fully insured were in meetings and negotiations and half with their government mortgages and zero equity never did repair. God bless your right to vote and post anyway. I hope the viewpoint expressed is soundly defeated in November.

Again, I too think people should only insure what they cannot afford to do themselves. They make free choices. But medical is different. If I have a heart attack, I don't have a "choice".

As usual, our points miss each other. There are many many many many many many choices made in health care, most with which I disagree.

People inform themselves and get a second opinion in medicine all the time. You have never second guessed a doctor?

"do I want the lowest cost, poorly trained doctor to set it?"

There isn't a poorly trained or low cost doctor in this country, but it is under central control where you will lose the power to make that choice. You don't see that?

"I don't care about the motorcycle. It's trash. I can buy another one (I've given up and gone to bicycles). Your theory only pertains to vehicle insurance. "

No! Tedious comes to mind. We were discussing healthcare insurance. Please focus. You can buy a policy to cover the ambulance and all the emergency care, bone setting heart transplant, anything, what on earth is the problem? In a free market, you might be able to buy a policy to cover only that and not all the procedures that you consider non-essential but others demand. Still you miss the point and call me wrong. You WILL lose the right to ride the motorcycle - symbolic for all those types of choices that someone else paying your bills determines to be too risky.

Why don't you push to have government regulate commerce like requiring complete disclosures of prices instead of having government participate in the commerce.

Why don't consumers organize and take over negotiations with the providers if they don't like the way they are treated. I know someone who did - a major labor union - and they self-insure. Government isn't the only lever. Were you going to get me an example of where a free market could not contain costs better than central control?

Rationing who gets what service is not lowering costs.

Why did healthcare go okay the first 200 years of so?

If we want to change the role of the federal government, why not go through the old fashioned process of AMENDING THE CONSTITUTION first, if it is such a good idea?

What other rights involve mandating someone else supply the product or perform the service for you?

Why no comment on GM's analogy? No one offers to pay for the right to bear arms but BCP at no additional charge is a right higher than self defense?

"I don't want cripples on the street because they couldn't afford to have their leg set."

Yeah, America was so cruel before Pelosi-Obamacare. Cripples on the street, that is why we chose tyranny over freedom. Who was denied that type of service, where, when? Nothing sells liberalism like lying.

Were you going to get me an example of where a free market could not contain costs better than central control?

Life expectancy at birth in the USA is 50th in the world, below most developed nations and some developing nations. It is below the average life expectancy for the European Union. The World Health Organization (WHO), in 2000, ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study). The Commonwealth Fund ranked the United States last in the quality of health care among similar countries,and notes U.S. care costs the most.

We spend and spend, but we don't deliver. Almost all major countries have a national health care plan (central control); one that cost's less than ours and delivers more.

Bottom line, if you are rich and/or have great insurance you get great care in America; if not, you get marginal care at best in the United States.

If we want to change the role of the federal government, why not go through the old fashioned process of AMENDING THE CONSTITUTION first, if it is such a good idea?

I don't think there is a need to amend the constitution; we will see how the Court rules...

"I don't want cripples on the street because they couldn't afford to have their leg set."

Yeah, America was so cruel before Pelosi-Obamacare. Cripples on the street, that is why we chose tyranny over freedom. Who was denied that type of service, where, when? Nothing sells liberalism like lying.

Study after study will show that the quality of medical care provided indigent patients is far lower than rich or fully insured patients. And that's a fact; no one is lying.Then again, you might argue, if they can't pay for it, they don't deserve treatment, right? Let the free market (those who have money) dictate who gets medical care and the quality thereof.